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Sabina Abidi MD FRCPCChild/Adolescent PsychiatristAssistant Professor Dalhousie UniversityIWK Youth Psychosis TeamNova Scotia Early Psychosis Program
Objectives Review the history of psychosis and psychotic disorders, current definitions and symptoms. Know the markers that help identify youth at risk for psychosis and psychotic disorders. Discuss the importance of early identification and treatment of youth with psychosis and psychotic disorders.
“So…let’s talk about psychosis…” What IS IT? Who knows? Definition Cases
Psychosis is a brain disorder. A medical illness - affects more than 8% of Canadians at any point in time a serious disturbance in an individual’s reality testing A process whereby the senses are distorted, making it difficult for the person to distinguish between real and unreal Affects a person’s ability to think, perceive and act Thinking, feelings, perception and behavior affected
Normal Teen Brain Development Lenroot & Giedd (2006)
Onset of Psychiatric Disorders in Adolescence Prevalence in Prevalence in Childhood Adolescence Depression (1-2%) Depression (6-8%) Bipolar Disorder (rare) Bipolar Disorder (1%) Psychosis (rare) Psychosis (1%)?? Anxiety Disorders (6-8%) Anxiety Disorders (10%) Anorexia Nervosa (rare) Anorexia Nervosa (0.2%) Total (7-10%) Total (15 – 20%)
Prevalence of Psychotic spectrum disorders per 1000 children/adolescents In males particularly, psychotic disorder(s) is Boys8 a major disorder of adolescence Girls Hits adolescents in their prime – leads6 to a disruption in education-attainment, career building, employment Alters relationships, family interactions,4 Alters sense of self, esteem, (Reprinted) Spady et al. Prevalence of Mental Disorders in Children productivity Living in Alberta, Canada, as Determined from Physician Billing Data. 2001.Arch Pediatr Adolesc Med. 155: pp.1156.20 Age 0 3 6 9 12 15 18
Symptoms of Psychosis What are common types of psychotic experiences?
Positive Symptoms Positive symptoms are things added in to people’s senses/thoughts/feelings/behaviour that are not normally there.
Positive symptoms include: Hallucinations Delusions Thought Disorder Disorganized or Unusual behaviour
Hallucinations Hallucinations can affect all senses: Sensory perceptions that occur in the absence of any real stimulus but appear to be the result of faulty messages in the brain. Hearing (auditory) Seeing (visual) Touch (tactile) Smell (olfactory) Taste (gustatory)
Delusions Fixed beliefs created by illness which are held only by the person experiencing the psychosis.These can include: Belief in special abilities of self or others Belief that physical health is changed Belief that unusual coincidences have a special importance Belief that one is being controlled
Thought Disorder Problems organizing thoughts. Thoughts coming to fast or too slow. Problems thinking and therefore speaking logically. Problems keeping on topic.
Disorganized or Bizarre Behaviour: Everyone’s behaviour is a response to how they interpret what is going on around them. People with psychosis may behave differently than they usually do. may become extremely active or agitated, may laugh inappropriately or display inappropriate appearance, hygiene or conduct. may behave in ways that reflect their thoughts
Negative SymptomsNegative symptoms refer to behaviours or experiencesthat have been reduced or lost because of the illness.
Negative symptoms may include: Problems getting motivated Problems taking joy in things Problems getting words out Seeming flat and blunted
Cognitive Symptoms Refers to problems with learning and concentration Find it difficult to focus and pay attention find it hard to filter out all the various stimuli in their environment. (may be highly sensitive to sounds, lights and even the regular activities occurring in their immediate environment.) Easily distracted Trouble with working memory Classroom/Tim’s example
Cognitive Symptoms find the ability and speed in processing information and reaction time may be slowed experience difficulties with memory, problem solving ability and judgement. find it hard to organize activities in their lives, for example to manage the time and tasks needed to get their schoolwork completed.
Mood SymptomsThe person can be Anxious, irritable Depression Anger and unpleasant behaviour Rapid changes in mood
Key Point•Sometimes people with psychosis cannotrecognize that they are ill and believe thatnothing is wrong with them.•This lack of insight can make it hard to getthe person to accept treatment.
The psychosis continuum or spectrum of symptoms Psychotic disorderPsychotic like experiences (schizophrenia)(normal variant) PLEs associated with other disorders -anxiety -Depression -Stress PLEs + markers of risk -Grief/loss - family history -trauma - social isolation - birth trauma - cannabis exposure
Types of disorders which present with symptoms of psychosis Schizophrenia Schizophreniform Disorder Brief Psychosis Schizoaffective Disorder Psychosis NOS Delusional Disorder Drug Induced Psychosis Bipolar Disorder (with psychosis) Psychotic Depression Secondary to a medical condition
To be normal in adolescence it itself abnormal Anna Freud
Prevalence of children’s mental disorders in Canada any disorder any anxiety disorder ADHD conduct disorder any depressive disorder substance abuse PDD OCD eating disorder Tourette syndrome schizophrenia bipolar disorder 0 3 6 9 12 15 estimated prevalence %Adapted from Table 2. Waddell et al. 2002. Child Psychiatric Epidemiology and Canadian Public Policy-Making. The state of the science and the art of the possible. Can JPsychiatry
Why the focus on psychosis/psychotic disorders?
• Common among prison and •More hospital beds inhomeless populations Canada are occupied (8%) by people with • 80% will abuse schizophrenia than by substances during their sufferers of any other lifetime medical condition • 15-25x more likely to die from a suicide attempt than the general “Youth’s Greatest Disabler” population • 10% or patients die from suicide most often in the first 10 years afterWorld Health Report 2001 diagnosis(WHO, 2002) schizophreniaand other forms of psychosesaffecting young people rankthird worldwide as the mostdisabling conditionIf left untreated, there is a continuing slow increase in impairment for years
Epidemiology Schizophrenia causes massive human and financial costs Affects more than 1% of the world’s population Affects all races, ethnicities, cultures equally More severe presentation in men Allow for a more broader definition of psychotic disorder (include psychosis NOS, brief episodes, delusional disorder) lifetime rate increases to 2-3%
Patients with schizophrenia itself die 12-15 years earlier before the average population – some quote up to 25 years earlier Schizophrenia causes more lives lost than cancer and physical illness Mostly due to poor medical care, suicide and deteriorating physical illness
The vast majority of psychiatric disorders have their onset in adolescence The age of maximum incidence for schizophrenia in males is 15-25 years and 18-35 years in females If left untreated, there is a continuing slow increase in impairment for years.
Life potential (social, occupational, financial…)OnsetOfillness Successive illness relapses 17 Age
Outcomes of psychiatric illness in adolescence X – onset ofAttainment – in life psychiatric illness X – onset of treatment effort X – delay in treatment 12 15 20 effort Time - age
Phases of Illness Birth Premorbid Phase First Signs of Illness Prodromal Phase Onset of Psychosis Duration of Untreated First Treatment PsychosisRecovery/Stabilization Phase Residual/Stable Phase
Etiology Risk Factors Genetic Family history of psychotic disorder/bipolar disorder Environmental Higher incidence in urban populations Immigrant ethnic groups - social isolation Areas of Social defeat Childhood trauma exposure Cannabis exposure Perinatal factors There is a definite interplay of genes and the environment
Genetics 50% of identical twins with a twin having schizophrenia will develop the disorder. 13% risk for children with one parents with schizophrenia. 2% risk for first cousins of a person with schizophrenia >1% risk for the general population.
Stress-Vulnerability Model of Schizophrenia High Stress Less severe Psychotic symptoms -adverse acute Psychotic-like & chronic life events Symptoms or - developmental Prodromal challenges symptoms No symptoms Low Low High Vulnerability -family history of psychotic disorders -Obstetric complications
It is important to remember thatpsychosis is not caused by: Family upbringing. Problems with other people. Having a “weak” character.
Dopamine in brain function Dopamine is important in three areas of brain function: Mesolimbic-frontal cortex circuits ( psychotic symptoms). Basal ganglia (control of muscle movement). Parkinson’s disease; loss of dopamine cells Hypothalamus-Pituitary (control of the hormone, prolactin).
Duration of Untreated Psychosis (DUP) Historically youth experience long DUP before coming into contact with psychiatric services 2-5 years Long DUPS translate to very poor clinical and social outcomes We now know that if this illness is caught early, prognosis can be very positive with effective treatment
Rational therapy for psychotic disorder Antipsychotic medication along with therapy/education are the cornerstone of effective treatment programs when dealing with a known chronic psychotic illness such as schizophrenia
Antipsychotic Medications All antipsychotic medications influence communication between brain cells involving the neurotransmitter, dopamine. Each medication may also influence a number of other neurotransmitters in the brain, but the effect on dopamine seems to be one common factor in reducing psychosis.
First and Second Generation Antipsychotics “Traditional” or “First Generation” antipsychotic medications (1950-1988) (dopamine blockade): Haloperidol, Chlorpromazine, Thioridazine and many others. Second Generation antipsychotics (serotonin- dopamine antagonism) “Clozapine / Clozaril (1990) Risperidone / Risperdal (1992) Olanzapine / Zyprexa (1996) Quetiapine / Seroquel (1998) Ziprasidone / Zeldox (2008) Paliperidone / Invega (2008) Aripiprazole (Abilify, 2009)
Side effects First generation (due to Dopamine receptor blockade): Extrapyramidal (movement) symptoms (EPS) Muscle stiffness, restlessness, involuntary movements. The use of anti-parkinsonian “side effect” meds. Prolactin (hormonal) elevation. Ammenorhea and sexual dysfunction “Dysphoria” (feeling bad). Difficulty with concentration and memory.
Side effects Second generation antipsychotics: Sedation (early in treatment) Sexual dysfunction Weight gain Metabolic dysregulation Dylipidemia Hypertriglyceridemia Risk for diabetes Cardiac dysfunction Glaucoma Stroke Extrapyramidal side effects still a concern
General treatment guidelines Individual basis Try to treat with one medication at a time. If there is an insufficient clinical improvement after 3- 6 months, try a different medication. Use continuous treatment with medication for as long as possible.
Treatment: How Long? 50% of patients who do not take medication in the first year will relapse
Treatment 40-60% with effective treatment (medicine, therapy, education, rehabilitation) can lead productive lives achieving life goals had prior to the onset of illness
Key Points Psychosis is treatable. Medication is a necessary, but not sufficient, part of a total treatment plan. The stress-vulnerability model helps us understand treatment. Adherence with treatment, including medications, is a critical issue.
Challenges to Treatment Non-adherence Depression/risk of suicide Substance use/abuse Excessive stress/expectations
Predictors of Non-Adherence Denial of illness Support Network Symptoms of Illness Stigma Delusions Insight Depression Distressed by side effects Cognitive impairment Drug induced dysphoria Belief that medications no (feeling bad) or longer needed (I’m cured). akathisia (restlessness) Attitudes of family and Cost of Medication friends
Depression Major depression during course of illness : 60% Post-psychotic Depression: 25% Attempted suicide: 25% - 40% Successful suicide: 10% - 13%
Challenges: Substance Use/Abuse Substance use is very common in first episode psychosis Up to 80% Cannabis and alcohol are most frequently abused substances
Cannabis and Early Psychosis People with psychotic disorders have higher rates of cannabis use than the general population Cannabis use is associated with poorer functional and clinical outcomes in this population, e.g. greater psychotic symptom severity the effects of which can last up to 4 years later Cannabis misuse associated with 4 times the risk of psychotic relapse One of the strongest predictors or risk factors associated with the onset of psychotic illness There is little evidence that the high rates if cannabis are is related to self-medication for distressing symptoms or side effects of meds
Common Issues in Recovery Daily Life Relationships Lack of Trying to establish independence structure/disorganization from family Lack of supports required Loneliness/Separation from social to return to school or work groups Negative experiences Increased anxiety in social groups No plan to help recovery Difficulties in re-establishing Lack of motivation relationships Recovery takes time
Prevalence of Psychotic spectrum disorders per 1000 children/adolescents Boys8 In males Girls particularly, schizophrenia is a major disorder of adolescence Hits adolescents in their prime – leads6 to a disruption in education-attainment, career building, employment Alters relationships, family interactions,4 (Reprinted) Spady et al. Prevalence support of Mental Disorders in Children Living in Alberta, Canada, as Alters sense of self, esteem, Determined from Physician Billing Data. 2001.Arch Pediatr Adolesc productivity Med. 155: pp.1156.20 Age 0 3 6 9 12 15 18
Phases of Illness Birth Premorbid Phase First Signs of Illness Prodromal ?Primary prevention Phase Onset of Psychosis Duration of Secondary Untreated prevention First Treatment PsychosisRecovery/Stabilization Phase Residual/Stable Phase
“It is not an easy task to recognize psychosis in the early stages and motivate a young psychotic person, who might have persecutory delusions or other delusional beliefs, to accept psychiatric treatment.” Nordentoft M et al. Does a detection team shorten duration of untreated psychosis? Early Intervention in Psychiatry 2008;2 :22-26.
Challenges in identifying the prepsychotic phase – The earliest symptoms identified are non-specific: Sleep disturbance behavioral disturbance Depressed mood social withdrawal Anxiety irritability In youth, changes that occur as part of the normal developmental continuum can complicate psychiatric diagnoses. Patient age, gender, developmental stage, identity, culture, belief system are all significant diagnostic and therapeutic factors The differential diagnosis for psychosis is widespread in youth and depends upon a number of environmental factors that must be examined 40% cases – initial diagnosis has cause to be changed in 3 months
Recognition of youth in trouble Less than ½ of child & adolescent psychiatric disorders are identified in primary care settings & only a fraction are referred for mental health services
Recognition of youth in trouble Direction of help-seeking behavior Help seeking behavior in adolescents is primarily directed to friends, family and teachers before physicians
Warning signs Gradual onset of change in behavior, appearance, attitude etc “he’s not himself”, “something’s up with him” Isolation from friends, adopting new/unusual friend group Decline in grades and overall functioning over time Poor hygiene Onset or increase in substance abuse, esp marijuana Odd or bizarre comments, beliefs, behaviors Easily distracted, sensitive to noise/light, wearing headphones often with little eye contact Appearing to be “out of touch” or daydreaming a lot, staring Low mood, frustration, irritability, sadness, confusion Avoiding hallways, crowds, buses Fatigue during day (poor sleep)
How can you help? Early identification What do these youth really look like? Support Reduce stigma/increase acceptance Substance use declining grades/functioning changes in behavior Help access service/assessment
Studies are now showing with earlier identification there is a decline in the transition rate to psychotic disorder in youth at high risk.
www.e-earlypsychosis.ca www.psychosissucks.ca www.teenmentalhealth.org IWK Health Centre Youth Psychosis Team 464-4110 (Central Referral) Nova Scotia Early Psychosis program 473-2976